The Most rapid recurrent meningioma: Case report and literature review

Introduction Meningioma, a primary intracranial neoplasm, accounts for 36 % of all primary brain tumors. Approximately 90 % of cases are benign. Malignant, atypical and anaplastic meningioma potentially have more recurrence risk. In this paper, we report a rapid recurrence of meningioma that is probably the most rapid recurrence for either benign or malignant type. Case presentation This paper reports a case of rapid meningioma recurrence 38 days after the first surgical resection. The histopathological examination showed suspicion of anaplastic meningioma (WHO grade III). The patient has a history of breast cancer. After total surgical resection, there was no recurrence reported until three months, and the patient was planned for radiotherapy. Only several cases have been reported about the recurrence of meningioma. With recurrence the prognosis is poor, and two patients died several days after treatment. The primary treatment for the entire tumor was surgical resection, and several issues were combined with radiotherapy. In this case, the recurrence time from the first surgery was 38 days. The most rapid recurrent meningioma reported to this day was 43 days. Conclusion This case report showed the most rapid onset of recurrent meningioma. Therefore this study cannot show reasons for the rapid onset of recurrence.


Introduction
Meningioma is one of the major subgroups of intracranial neoplasms that account for around 36 % of all primary brain tumors [1]. Approximately 90 % of meningioma cases are benign. According to the WHO classifications, grade I meningioma is the most common subtype, whereas grades II and III are designated for atypical and anaplastic neoplasms, respectively [2]. Surgical resection is a significant and effective treatment for meningioma. The atypical and anaplastic meningioma are potentially more recurrence risk (29-52 % and 50-94 %, respectively) than type I meningioma (~10 %) after complete resection [3]. This paper reports a case of rapid meningioma recurrence in one month. We did not find any examination that indicates it was a malignant or benign type of meningioma. Based on the summary of the literature review that we have seen, this case probably has the most rapid recurrence time for either benign or malignant meningioma. This case report has been reported in line with the SCARE Guideline Criteria 2020 [4].

Case presentation
A 54-year-old woman was brought to the emergency department complaining of weakness in the left arm and leg for four days and persistent headaches for one month. The headache was getting worse for the past week with nausea without vomiting. The patient also complained there was a lump on the right side of the head since three months ago, which was increasing. Based on the historical anamnesis, the patient has a history of left breast cancer and had a tumor resection one year ago.
Based on physical examination, the patient is fully-conscious (GCS E4-M6-V5), and there was a left hemiparesis. There was a lump in the right frontal; the patient had been examined with head computed tomography (CT) with contrast two months before. Based on the first head CT with distinction, there was a solid mass, extra-axial supratentorial, lobulated edges, measuring 3.8 × 3.1 × 3.2 cm in the convexity of the right frontal bone, and there was substantial heterogeneous contrast enhancement ( Fig. 1A-C). The patient evaluated the CT scan with contrast in the emergency department. The result showed that the mass was progressively growing with the size of 5.8 × 5.0 × 5.1 cm and pressing the right frontal lobe to the medial side, causing a midline shift of 0.9 cm (Fig. 1D).
A histopathological examination was not performed on the patient because it was considered possibly benign meningioma. Then the patient planned surgery for tumor excision. Right frontal craniotomy carried out total tumor resection ( Fig. 2A). Then the patient was evaluated three days after surgery; based on the physical examination, the patient was fully conscious and without neurological deficit. After five days of evaluation in the hospital, the patient was fully recovered and out of the hospital. The patient did not plan additional treatment (e.g., radiotherapy).
Thirty-eight days after the first surgical resection, the patient came to the outpatient clinic due to a left hemiparesis. The patient was planned to head a CT scan examination. Head CT scan examination showed the mass was re-growing with the size of 3.0 × 4.0 cm in the exact location ( Fig. 1E-F). Then the patient was planned for pre-surgical resection of the recurrence tumor. One week after the patient came to the clinic, awaiting the assignment of the surgical schedule, the patient was brought to the emergency department due to loss of consciousness (E1-M4-V1), hemiparesis, and there was anisocoria pupil. Then the head CT evaluation was performed in the emergency department and showed a result size of 3.0 × 4.2 cm, and there was focal brain edema (Fig. 1H). The patient was planned for urgent surgical resection (Fig. 2B). Then the tumor tissue was examined with histopathological examination.
Based on the results of histopathological examination, it was found that spindle cells with moderate to severe atypical oval nuclei formed a whirlpool with abnormal mitoses. The tumor preparations also found bleeding; some tissue had extensive necrosis (Fig. 3). Based on the results of this examination, it was concluded that the pathological diagnosis was suspicion of anaplastic meningioma (WHO grade III). The limitation of this case is not being able to determine whether the tumor cells are primary or are metastases from previous cancers due to the lack of availability of immunohistochemistry examination. The patient's  outcome was good, the patient was compos mentis on five days postsurgery, but there was still slightly left hemiparesis. There was no recurrence report until three months after surgery, and the patient was planned for radiotherapy.

Discussion
Only several cases have been reported of meningioma recurrence ( Table 1). Most of the tumor sites were in the frontal or temporal region. In this case report, the tumor site was in the frontal region, both primary and recurrence tumors. The main clinical manifestation was contralateral hemiparesis. Several cases also have the main clinical manifestation of hemiparesis [5]. The primary clinical manifestation mostly depends on the location of the mass.
The primary treatment for the entire tumor was treated with surgical resection (total or subtotal), and several cases had been combined with radiotherapy. In this case, we only treated the patient with complete surgical resection. The use of adjuvant radiotherapy in high-grade meningioma management remains controversial. No significant correlation was identified between postoperative radiation and the outcome of recurrent high-grade meningioma [6]. In the summary of cases (Table 1), there was only one study that reported full recovery of patients with atypical meningioma (WHO grade II) that were treated with radiotherapy [7].
Based on the summary of several cases, most have poor prognostic of recurrence, and in two cases, the patient died several days after treatment. The prognosis of anaplastic meningioma type is poor, with high recurrence rates. Overall, the survival time is less than two years, and the median time to recurrence is 9.6-42.1 months [8]. In this case, the recurrence time from the first surgery was 38 days. The most rapid recurrent meningioma reported to this day was 43 days [9].
The most rapid recurrence study [9] states that the short time to recurrence might correlate to the sub-total removal even though the authors underlined that the extent of surgery is not associated with the onset of recurrence. The possible cause, in this case, is a hormonal influence on tumor formation and progression due to the patient's historical breast cancer disease. Schoenberg et al. in 1975 [10] described, for the first time, an increased incidence of meningiomas in a group of patients diagnosed with breast cancer. In 1979 Donnell et al. [11] described the importance of estrogen receptors (ER) and progesterone receptors (PR) in meningioma cells. The absence of PR's or ER's expression is related to more aggressive behavior, higher risk of progression, and higher recurrence [12]. However, this case report cannot directly show the association between the rapid onset of recurrence with breast cancer. Therefore, it needs further study to identify the correlation.

Conclusion
This case report showed the most rapid onset of recurrence of meningioma. Therefore, this study cannot show the associated factor the rapid onset of recurrence. This case also showed that total resection could give good prognostic of patient survival in recurrent meningioma.

Consent
Written informed consent was obtained from the patient and family.

Ethics approval
The study includes human participants to report was approved by the ethics committee of Soebandi General Hospital.